Appeal Rights

If the provider disagrees with the initial decision, the request for an appeal should be sent to the following address:

If including a copy of the UB-92 for the claim, please make sure it is only a copy. Do not submit originals of the UB-92 to the Appeals Department.

If the provider disagrees with the decision on a redetermination (i.e., 1st level appeal decision) the request for the next level of appeal should be sent to the qualified independent contractor (QIC). This information is on the “Reconsideration Request Form” sent with the redetermination letter.

For some issues, the provider does not need to request a redetermination. There are several simple clerical errors that can be corrected by requesting a “clerical error/omission reopening.” A “Clerical Error/Omission Reopening Form” has been designed to help providers with their request. This form is not required. However, it has been set up to contain all of the information needed to help process the request quickly and accurately. It also clearly indicates which types of errors can be corrected using this process. *Please be aware that supporting documentation MUST accompany these requests or the reopening will not be allowed.

Previously, providers could only appeal a claim determination when (1) the item/service was not covered because it constituted custodial care, was not reasonable and necessary, or for certain other reasons and (2) the provider knew, or could reasonably have been expected to know, that the service in question was not covered under Medicare (that is, there was a finding with respect to the limitation of liability provision under section 1879 of the Act).

For initial determinations made on or after May 1, 2005, providers who submit claims to FIs will have the same right to appeal claims as beneficiaries. This means the provider does not need to submit an Appointment of Representative form for initial determinations made on or after May 1, 2005.

In addition, for redetermination decisions issued on or after May 1, 2005, the provider will have the right to appeal a dismissal of the redetermination request to a QIC (qualified independent contractor). Incomplete requests will also be dismissed.

The provider may appeal these dismissals under the following circumstances:

1. 1) If the provider thinks there is good and sufficient cause for filing late, the FI may be asked to vacate the dismissal. We will vacate our dismissal if it is determined that there is good and sufficient cause for filing late. If the provider would like to request the FI to vacate this dismissal, a request must be filed within 6 months of the date of this notice. In the request, please explain why you believe that there is good and sufficient cause for filing late. Please send your request to:
   

   National Government Services, LLC.
   Attention Appeals Department
   P.O. Box 3035
   Milwaukee, WI 53201-3035
   ** This Now Includes All California Providers **

2. If the provider thinks the request has been incorrectly dismissed (for example, you believe you did file your request on time), the provider may request a reconsideration of the dismissal by a Qualified Independent Contractor (QIC). The request must be filed within 60 days of receipt of this letter. The QIC will have 60 days to complete the reconsideration. In the request, please explain why it is believed the dismissal was incorrect. Please note that the QIC will not consider any evidence for establishing coverage of the claim(s) being appealed. The QIC examination will be limited to whether the dismissal was appropriate.
   

   Information regarding the appropriate QIC can be found on the “Reconsideration Request Form” included with the dismissal letter.

   If the appeal request was dismissed as incomplete, the provider also has the option to re-file the request if any time remains in the filing period (i.e., within 120 days of receipt of the initial determination). When a request is re-filed that meets the requirements, the previous dismissal will be vacated.

The street address for National Government Services (formerly United Government Services, LLC.) is: